CHEST Guidelines-A-Man-in-His-70s-With-Hypotension-and-Increasing-A

A-Man-in-His-70s-With-Hypotension-and-Increasing-A

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A man in his 70s with a history of coronary artery disease, heart failure, and past colon cancer surgery, presented to the emergency room with altered mental status and was found to have acute decompensated heart failure, and liver and kidney failure. Despite no recent prescription medications, he worsened in the hospital, showing signs of hemorrhagic shock after undergoing a liver biopsy. CT scans revealed liver abnormalities, and a subsequent core biopsy led to a significant drop in hemoglobin, requiring blood transfusions. About 30 hours after the biopsy, he had a rapid decline in blood pressure, abdominal distension, pallor, and cool extremities.<br /><br />A bedside ultrasound identified hemoperitoneum, a critical internal abdominal bleed, showing echogenic signs of blood and other particles, indicating ongoing bleeding. The patient was in a hypovolemic shock state, confirmed by the near collapse of his inferior vena cava. As a result, an emergency decompressive paracentesis was performed, removing blood from the abdominal cavity and initiating a massive transfusion, returning circulation within minutes. Post-arterial embolization of the liver stopped the bleeding, yet the patient's encephalopathy persisted, and he was later discharged to hospice.<br /><br />This case underscores the critical role of bedside ultrasound in quickly diagnosing hemoperitoneum, aiding immediate clinical response and guiding resuscitation in unstable patients. FAST ultrasounds have shown high sensitivity for detecting intraperitoneal bleeding and offer real-time diagnostic benefits over CT, especially when patients are too unstable to transport. Ultrasound findings such as fibrinous strands and hematocrit signs are crucial for quick identification and management of abdominal bleeding emergencies.

Keywords

acute decompensated heart failure

hemorrhagic shock

liver biopsy

hemoperitoneum

hypovolemic shock

bedside ultrasound

FAST ultrasound

arterial embolization

intraperitoneal bleeding

emergency decompressive paracentesis